1. What are some contraindications to a lumbar puncture?
    • Evidence of IICP
    • If suspected, intracranial tumor (can cause shifting)
    • Decubitous infection where the puncture site is
  2. What pre-procedure measures need to be carried out before an LP?
    • Consent Empty bladder (may need a Foley)
    • Pt education (purpose, position, risks, local anesthetic, ect.)
    • e.g. take 8-10 ml of fluid (about 2-3 test tubes), bedrest for 4-6 hrs, can turn side to side, continuous VS
  3. How can bedrest assist and support the pt during an LP?
    • Help curl them
    • Relaxation, calming
    • Explaining
  4. what laboratory studies would you expect to be ordered on the CSF sample?
    • RBCs, PR, glucose, WBCs
    • expect the first stick to be bloody
    • if couldy-infection
    • if brown/orange/yellow-inc in PRO
  5. what post procedure restrictions can you expect and prepare the pt for?
    • check VS
    • may be on bedrest
    • fluids to restore fluid volume and prevent spinal headaches
  6. what complications do you need to monitor the pt for?
    • spinal headaches
    • hemmorhage
    • brown /orange/yellow CSF-inc PRO
    • cloudy-infection
    • nucal rigidity-stiff neck from menningeal irritation
    • transient difficulty voiding
    • extreme pain in back, radiationg to thigh
    • may need a bandaid or patch to dec sepage
    • document the procedure, was the pt cooperative, outcomes
    • viral menningitis if under 5, bacterial if over 5
  7. temperature-indications of change in neuro
    • hyperthermia raises metabolic demands of the brain, hypothermia can cause cardiac arryhthmias
    • hypothermia is sometimes used to treat IICP
  8. respirations-indications of a change in neuro
    elevated levels of CO2 will cause vasodilatation and increased cerebral blood flow
  9. Cheyne-Strokes Respirations-indications of a change in neuro
    alternately crescendos to to hypernea and decrescendos to apnea. (bilateral cerebral hemispheres, basal ganglia)
  10. Cushing's Triad/wide pulse presure-indications in a change in neuro
    • increased systolic BP greater than the increase in diastolic pressure, decreased HR and respiratory rate
    • opposite of shock signs: dec BP, inc HR and inc respiratory rate
    • wide pulse pressure-systolic doesn't change or slightly changes, while diastolic continues to drop
  11. assessment of reflex activity-neuro assessment
    • blink (protective)-move hand quickly toward eyes
    • corneal-check with Q-tip
    • gag/swallow
    • plantar (Babinski)-stroke lateral aspect of foot. Normal-flexion of toes, Abnormal-great toe dorsiflexes, other toes fan. Positive Babinski-indicates an upper motor neuron lesion. Usually those older than 2 should have a negative Babinskis. Possible to have both positve and negative (e.g. could have different results for each foot)
  12. posturing-neuro assessment
    • abnormal movements-seizures, tremors
    • muscle corrdination-any injury/disease that involves the cerebellum or basal ganglia will affect coordination) i.e.ask to close eyes & touch finger to nose
  13. assessment of sensory function-neuro assessment
    • central and peripheral vision-ask pt to read something
    • hearing/ability to understand verbal communication
    • superficial sensation-touch, pain
    • -start at furthest point and move toward trunk
    • -check dull/sharp pain
    • -hot/cold
    • -positioning-moving a finger or toe, turn pt away and move pts finger/toe and ask them what you're doing
  14. neuro assessment-history
    • past diseases
    • traumatic injury
    • factors that exacerbate or alleviate sx
    • family hx-DM, CVD, HTN, cancer, neuro diseases
    • social hx/habits-smoking, drug use, alcohol use, occupation, ect
    • meds-Neurotin (peripheral neuropathy-DM, spinal stenosis)
  15. general observations-neuro assessment
    • appearance and behavior:
    • dress, grooming
    • facial expression, ptosis (drooping, common in myasthenia gravis)
    • mood-depressed, euphoric, angry
  16. sequence of stimulation
    • Voice
    • Shout
    • Shake
    • Pain
  17. assessment of mental status
    • consciousness-implies awareness and response to stimuli
    • unconsciousness-depressed, cerebral function, inability to respond to sensory stimuli
  18. assessment of mental status-evaluation of consciousness
    • orientation-in order of what we lose first
    • Time
    • Place
    • Person

    -be aware of what is in pt's room-e.g. clock, date, ask things more specific like what tv show are you watching, what did the weatherman just say
  19. assessment of mental status-evaluation of consciousness
    • attention span
    • do you have to keep stimulating pt?
    • are they staying focused?

    -note that pain meds can alter attention so be aware
  20. assessment of mental status-evaluation of consciousness
    • language and speech
    • are responses clear/understandable/slurred/garbled-be aware of meds given
  21. assessment of mental status-evaluation of consciousness
    • memory
    • check remote, recent (recall), and new
    • long-term (remote) i.e. where were u born? (very few people lose)
    • short-term (recent) i.e. who brought you to the hospital, what happened?
    • new-give three step command to follow

    early loss of memory (recent)-shows neurologic problem in early stages
  22. levels of consciousness
    • most important party of neuro exam
    • awake, alert, oriented
    • confusion-misinterpret stimuli, short attention span, disoriented to time
    • delirium-restless, agitated, irritable, disoriented, combative
    • lethargic-drowsy, but awakens with stimulation, able to answer questions and follow commands slowly
    • stupor-very drowsy, generally inresponsive, briefly aroused after repeated painful stimuli-may moan or withdraw from stimuli but doesn't follow commands
    • coma-does not respond to continuous stimuli, doesn't move

    better to describe than label e.g. drowsy, but awakens with stimuli, follows commands slowly-rather than saying lethargic
  23. when assessing LOC-may use Glasgow Coma Scale
    • based on ability to respond and communicate
    • eliminates ambiguous terms

    • based on 3 responses:
    • eye opening
    • motor response
    • verbal response
    • score range-3-15
  24. eye opening
    • 4=spontaneous
    • 3=to voice
    • 2=to pain
    • 1=none
  25. best motor response
    • 6=obeys commands
    • 5=localizes
    • 4=withdraws
    • 3=abnormal flexion (decordicate posture)
    • 2=abnormal extension (decerebrate posture)
    • 1=flaccid-no response
  26. types of stimulation
    • trapezius squeeze-be careful, can pinch a nerve
    • supra-orbital pressure
    • sternal rub-most invasive
    • nailbed pressure-least invasive
  27. best verbal response
    • 5=oriented
    • 4=confused
    • 3=inappropriate words
    • 2=incomprehensible sounds
    • 1=none
  28. score of 7 or less indicates
  29. score of 13-14
  30. score of 9-12
  31. #2 optic
    #3 occulomotor
    • pupillary refelx
    • look at eyes with regular light and then flashlight
    • look for constriction/dilation
  32. #3 occulomotor
    #4 trochlear
    #6 abducens
    • eye movement
    • ask pt to follow your finger
  33. #5 trigeminal
    • corneal (blink) reflex
    • check with Q-tip
    • *if impaired may get corneal abrasions
  34. #7 facial
    ask to raise eyebrows, frown, smile, >>>look for symmetry
  35. #8 acoustic
  36. #9 glossopharyngeal
    #10 vagus
    • control cough and gag reflex
    • check with tongue blade and ask to cough
    • *if impaired, may aspirate
  37. #11 spinal accessory
    place hands on shoulds and ask them to shrug shoulders
  38. #12 hypoglossal
    • tongue movement
    • ask to stick out tongue
    • deviation occurs on weak side
  39. assessment of extremity movement
    • does pt move all four extremities with equal strength?
    • ask to follow commands-i.e. hold up right hand
    • *hand grasp may be misleading -may not be able to follow commands but may have a strong grasp reflex like in infants
    • may have strong grasp with frontal lobe damage
    • carpal tunnel-ccan have weak grasp

    • check muscle strength
    • have pt push nurses hands with soles of feet (plantar and dorsal flex)
    • hand grasps
    • abnormal movements-seizures and tremors
    • ulnar drift-close eyes and hold arms with palms up for 20-30 sec. if one arm falls, weak muscle strengh, positive ulnar drift
  40. posturing (abnormal spontaneous movement or a response to painful stimuli)
    • decordicate (flexion posture)
    • decerebrate (rigid extension)

    posturing may be unilateral, bilateral or mixed

    muscle tone-rigidity, spasticity, flaccidity
  41. decordicate posture
    • occurs with lesions of cerebral hemispheres
    • arms flex at elbows, legs extend with internal rotation
    • decordicate-arms move toward core
    • C=cerebral hemispheres
    • cerebral lesions
  42. decerebrate posture
    • occurs with brain stem damage
    • all four extremities rigidly extend
    • dEcErEbratE E=extension
    • decereBrate B=brainstem
    • brainstem damage
  43. pupil checks
    size-normal, contricted, dilated?

    • constricted?-if taking narcotics
    • pinpoint?-if on glaucoma eye gtts or may be d/t pons damage (brainstem)
    • dilated-bilaterally dilated?-if on Atropine or hypoxic

    • equality-grossly unequal pupils>>danger sign
    • **25% people have unequal pupils

    • reaction-brisk, sluggish, fixed PERLA/PERRLA
    • *don't expect a reaction from a blind or false eye

    • position-midline or deviated from midline
    • deviated to the side, could be lazy eye

    • to check eyes, move light toward eye from the side
    • normally there is no involuntary movements of the eyes
    • pupil changes usually occur on the opposite side as the lesion

    direct response=when light is shined in eye, pupil contricts=keep opposite eye shut

    conjugate gaze-eyes track together to look at something i.e. follow finger
  44. epidural space
    • first space, can have a bleed here
    • arterial bleed with a head injury
    • need to be treated quickly
  45. dura mater
    • strong and fiborous
    • contains meningeal arteries
  46. subdural space
    • most common site of head trauma
    • can have a bleed here, venous bleed
    • slower, more common than epidural
  47. arachnoid mater
    • spidering/cobwebbing
    • contains blood vessels
    • has arachnoid vili that project into subdural space acting as an exit point for CSF
  48. subarachnoid space
    space that exits btwn the arachnoid and pia mater, filled with CSF
  49. cerebrum
    • 2 hemispheres
    • lesion on 1 side shows s/s on opposite side
  50. frontal lobe
    involves sense of ethical behavior, personality, abstract thoughts-concentration/memory, affect, Broca's motor speech-articulation and written speech, usually dominant in left hemisphere, important to know for head injuries and strokes
  51. parietal lobe
    • sensory discrimination-e.g. hot/cold, pain/pressure
    • spacial relation
    • speech area-Wernickies works with temporal lobe in interpreting and understanding speech and written word
  52. temporal lobe
    • hearing-helps to understand spoken word
    • olfaction
    • short-term memory
  53. occipital lobe
    helps integrate and interpret what we see-vision
  54. basal ganglia
    • suppossedly 4 actual masses in the bases of each hemisphere
    • steadying influence on muscle activity-esp. legs and hands, helps regulate posture
  55. hypothalmus
    • regulates temperature, appetite, water balance, and sleep
    • under the thalmus
    • emotions such as anger and fear
  56. cerebellum
    • lesion on one side>>s/s on same side
    • looks like caulliflower
    • muscle control/movement/tone/balance
    • fine motor control, proprioception-awareness of where body is
  57. thalmus
    relays (relay point( sensory and motor tracks, controls fear and instinct
  58. brainstem
    • gives rise to cranial nerves 3-12
    • midbrain
    • pons
    • medulla
    • protective reflexes-blink, gag, cough, swallow, sneeze, vomit-usually projectile
  59. midbrain
    conduction pathway and reflex center where cranial nerve 3-occulomotor nerve originates
  60. reticular formation
    • located in the brainstem and diencephalon-nerve network
    • supplies constant muscle stimulation to counteract gravity (why we can stand up)
    • recticular activationg system (RAS) is w/i the recticular formation
    • the RAS controls the sleep wakefulness cycle (conciousness and concentration)
  61. cerebral blood supply paired carotid and vertebral arteries
    • Circle of Willis-where a lot of aneursyms happen
    • HTN affects blood flow aiding in this
  62. ventricular system and CSF
    • 2 lateral, 3rd and 4th ventricle-these are spaces
    • ventricles contain choriod plexus which produces CSF

    • CSF-100-500 ml circulates at one time
    • clear, colorless, odorless
    • conatains PRO, glucose, chloride and 0-5 WBCs
    • provides nutrityion, cleans out organisms
    • if bloody-hemmorrhage or trauma
  63. glial cells
    support, protect, rapidly reproduce, cancer tumors grow fast b/c of these
  64. chemical neurotransmitters
    acetylcholine-causes muscles to contract

    norepinephrine-fight/flight response, increases metabolism

    dopamine-relaxes muscles

    • acetylcholinesterase-eats acetyllcholine then works with dopamine for muscle relaxation
    • not enough dopamine causes muscles to contract -e.g. Parkinson's
  65. brain metabolism relies on
    • CHO-if a dec. in glucose occurs>>seizures, coma
    • main source of energy for brain

    • oxygen-brain will get 20% O2 while at rest
    • get more while not at rest

    vitamin B-needed for nerve conduction
  66. blood brain barriers
    • complex of membranes in the choriod plexus
    • protectrs the brain from foreign substances

    • large molecules penetrate slowly-i.e. insulin
    • small molecules penetrate rapidly-i.e. urea-nitrogenous waste products from kidneys
    • some molecules cannot penetrate-i.e. dyes
  67. spine
    31 pair of spinal nerves

    • vertebral column
    • spinal cord
    • -*ends at L1/L2
    • -*the spinal cord joins the brain stem @ the foramen magnum
    • -*lumbar puncture (LP) is done btwn L4/L5
  68. autonomic nervous system
    controls body function

    • sympathetic-prepares body for fight/flight (stressful situations)
    • norepinephrine is associated with this

    • parasympathetic-slows body down and conserves energy
    • acetylcholine is associated with this
  69. peripheral nervous system
    • sensory/motor tracks of spinal nerves
    • -they sense and send back motor response
    • pyramidal-fine voluntary movementparalysis problems if lacking
    • extrapyramidal-gross motor movement and posture, involves cerebellum/reticular formation/basal ganglia-problem>>spasticity (psych meds remember cause extrapyramidal s/e like Haldol) Cerebral palsy, Parkinson's

    • cranial nerves
    • -12 cranial nerves
    • 1-4 eyes and ears
    • 3-occulomotor
    • 9-glossopharyngeal
    • 7-facial Bell's Palsy
  70. normal intracranial pressure fluctuates btwn..
    • 0-15 mm hg
    • increased pressure if above 15 mm hg

    • normal variations occur with:
    • coughing
    • sneezing
    • valsalva
    • isometric muscle contractions (pushing against bed with arms)
    • extreme hip flexion
    • standing up-causes a drop
  71. CPP-cerebral perfusion pressure
    • amount of pressure needed to deliver O2 and nutrients to the brain (effectiveness of cardiac output to maintain cerebral perfusion)
    • (normal CPP is above 70 mm hg)
  72. prinicples of IICP
    Kellie Monroe hypothesis
    the skill is a fixed sided box, containing brain tissue, CSF, and blood. the pressure within the box stays within 5-15 mm hg. if one or more contents of the box expands , there will come a point in time that the intracranial pressure will also increase

    cranial insult>tissue edema>IICP>compression of blood vessels>dec cerebral blood flow>dec O2 with death of brain cells>dec edema around necrotic tissue>IICP with compression of brainstem and respiratory center>accumulation of CO2>vasodilation>IICP resulting from inc blood volume>death
  73. causes of IICP
    • tumor
    • head injury
    • CVA
    • infection
    • abcess
    • birth trauma
    • hydrocephalus
    • *cerebral edema-most common caue, inc in water content, inc tissue volume, can be generalized-more severe or infection-menningitis and encephalitis are the two most common
  74. s/s if IICP
    cerebral edema-life threatening, inc bulk>>neurodeficits, exacerbation of IICP

    • LOC
    • motor strength
    • pupils
    • VS
  75. LOC
    LOC is the first to change

    • early signs-dec orientation
    • forgetfulness-mild confusion
    • restless
    • suddenly quiet after being restless
    • increased stimulation required to display same response-Voice, Shout, Shake, Pain

    • late signs-
    • difficult to arouse
    • dec GCS
  76. motor strength
    • early signs-
    • subtle weakness (contralateral)-opposite side
    • paresthesia

    • late signs-
    • pronator (arm) drift
    • extreme motor weakness followed by no response (flaccid)
    • hemiparesis
    • hemiplegia-opposite side, contralateral weakness, paralysis
  77. pupils
    • early signs-
    • may have double or blurred vision
    • -sluggish reaction
    • -unilateral progression>>dilation (usually occurs on affected side)

    late signs-

    • one fixed dilated pupil *neuro emergenecy
    • followed by both pupils fixed and dilated-big problem at this point
  78. VS
    • early signs-
    • no reliable changes
    • may have altered respiratory pattern such as Cheyne Strokes
    • temp elevation r/t hypothalmus dysfunction

    • late signs-
    • *Cushing's Triad
    • -systolic HTN (wide pulse pressure)
    • bradycardia
    • bradypnea
  79. s/s of IICP
    • headache
    • early signs-
    • usually present in AM
    • may be constant, inc in intensity, aggravated by movement

    • late signs-
    • possible seizure activity
    • loss of protective reflexes

    • vomiting
    • early signs-
    • occurs typically w/o nausea-projectile
    • may relieve headache

    • late signs-
    • changes in speech-slurred>>no speech

    • papilledema
    • may be first sign observed (by eye Dr)
  80. ICP monitoring
    • interventricular catheter
    • subarachnoid screw
    • extradural or epidural sensor
  81. tx of IICP
    • osmotic diuretic (Mannitol)-most common
    • causes water to shift from brain tissue into blood (decreases cerebral edema and slows CSF production)

    • given IVP or IVPB (may have bolus)
    • pre-op bf cataract surgery to dec edema
    • can dec pressure w/i 15 min-last for 3-8 hrs
    • *monitor UO 1-3 hrs diuresis should occur after infusion

    • s/e
    • can produce fluid/e-lyte imbalance and hypotension
    • monitor output, e-lytes, CVP, renal studies (may cause CHF/pulmonary edema with fluid shift from intracellular to intravascular)
  82. steroids
    • controversial
    • Decadron-a lot of controvery as to whether it helps or not
    • reduces cerebral edema, dec inflammation and inc. glucose to the brain b/c adrenal insufficiency>>colapse

    • can't be DC'd quickly b/c adrenal insufficiency>>cardiac collapse
    • monitor K+
    • check stools for occult blood
    • give protonix, pepcid-to dec GI irritation
  83. anticonvulsants
    • Dilantin, Cerebyx
    • prevent seizure activity
    • ***Dilantin-combine only with NS-it precipitates, give orally
    • monitor Dilantin levels
    • therapeutic-*10-20-like Theophylline

    • Cerebyx-sound a-like celebrex
    • not as many s/e as Dilantin
  84. loop diuretic
    • Lasix, Bumex
    • Adjunct
    • pools fluid off-Lasix is used more
  85. analgesia
    • Codeine or fentanyl (Sublimaze)
    • **doesn't depress respirations or LOC as much as other narcotics
    • Codeine is the drug of choice
    • dec agitation and supresses cough
  86. maintain CO2 level (maintain low normal side)
    • -pCO2=34-45
    • CO2 is a vasodilator
    • Dobutamine/Dopamine
    • hyperventilation dec CO2 which causes vasoconstriction of cerebral arteries >dec cerebral blood flow and dec ICP
    • **prolonged hyperventilation reducing cerebral perfusion can result in cerebral ischemia or infarction
    • Diprovan-dec metabolic needs, vent control
  87. surgical
    shunt ot allow drainage of CSF
  88. nursing interventions for IICP
    • ineffective airway clearance r/t diminished protective relfexes (coughing/gaging)
    • accumulation of secretions
    • maintain patent airway by-suction less than 10 sec
    • position in Semi-Fowler's at least 30 degrees
    • don't flex hips
    • turn head or them to the side
  89. nursing interventions for IICP
    • altered cerebral tissue perfusion r/t effects of IICP
    • don't flex hip (have extreme flexion)
    • keep neck in neutral position (use log roll to turn)
    • vent-PEEP setting for best oxygenation
    • stool softener to dec valsalva
    • dec activities that would increase ICP
    • no bright lights
    • turn-slow, gently, in one motion
    • SCD's
  90. nursing interventions for IICP
    • risk for infection r/t ICP monitoring system
    • meningitis-stiff neck (nucal rigidity), headache, fever, chills
  91. complications (PCs)
    • brainstem herniation
    • diabetes insipidus (if pituitary is affected)
    • -output over 200 ml/hr may indicate D.I.
    • -clear urine
    • are they on Manitol? Lasix? figure out what's causing it
  92. traumatic brain injury
    • leading cause of trauma death
    • death can occur immediately after injury, w/i 2 hrs, 3 wks or more later from multisystem failure

    • survivors may have long-term effects and deficits
    • cause-motor vehicle accidents, falls, violence
  93. types of injuries
    • fractures-
    • may be opened or closed

    • linear fracture-
    • common in temporal or parietal area
    • *commonly associated with epidural and subdural bleeds

    • basal fracture-
    • base of skull involving occipital, temporal, sphenoid or frontal bones
    • not usually life-threathening but may result in leakage of CSF and blood from the nose and ears (rhinorrhea/otorrhea)

    • s/s-
    • dec hearing with ruptured tympanic membrane or fluid behind the membrane

    • *battle sign-ecchymosis of mastoid process behind ear
    • *racoon eyes-periorbital bruising
    • *halo sign-CSF (spot on pillow case, red and pink in the middle, blot with 2x2, at risk for meningitis)
  94. what is the possible complication to monitor for with a basal skull fracture?
  95. closed head injury
    result of blunt trauma-may be serious because of chance for IICP

    • concussion
    • contusion
    • diffuse axonal injury
  96. contusion
    • more severe than a concussion
    • bruising, hemorrhage and edema of cerebral cortex-commonly affects the frontal and temporal lobes

    • unconscious lasting over 5 min
    • CNS dysfunction lasting 12 hrs to 5 days
  97. concussion
    • usually diagnosed by pt symptoms since there may not be any obvious physical injury
    • dizziness, spots before eyes, act dazed
    • brief loss of consciousness (usually less than 5 min.)
    • some confusion or amnesia to events prior to and after injury-retrograde amnesia
    • usually no residual deficits and CNS dysfuntion clears w/i 12 hrs
    • *severity of concussion correlates to duration of amnesia
  98. diffuse axonal injury
    • widespread damage to axons
    • immediate loss of consciousness, usually no lucid intervals
    • prolonged coma, decerebrate/decorticate posturing

    classified as mild, moderate, or severe
  99. coup
    • injury at point of impact
    • contusion occurs where brain is forced up against skull
  100. contre-coup
    injury occurs at point of impact and also where brain impacts the opposite side in rebound, more involved
  101. epidural hematoma
    • btwn the skull and dura
    • *arterial bleed is common in temporal lobe
    • *surgical emergency to evacuate the clot

    • s/s
    • typically brief loss of unconsciousness then return to normal
    • (lucid interval) for a few minutes/hrs then a rapid neurologic deterioration

    • constant headache
    • motor weakness
    • + Babinski
    • ipsilateral pupil dilation
    • vomiting
    • dec LOC
  102. subdural hematoma
    • below the dura
    • *venous bleed
    • s/s-
    • tend to develop slowly-have 48 hrs-may take 2-4 weeks
    • *more common in elderly and those on anticoagulants
    • increased drowsiness
    • confusion
    • mild persistent headache
  103. acute subdural hematoma
    s/s w/i 48 hrs
  104. subacute
    s/s w/i 48 hrs-2 wks
  105. *chronic
    • s/s w/i 3 wks-several months
    • esp with alcoholics from always falling and the elderly-experience brain atrophy increasing the size of the subdural space
  106. intracerebral hematoma
    • bleeding w/i the brain tissue that cannot be removed surgically
    • i.e. aneurysm
    nursing assessments
    • airway evaluation
    • is the pt able to ventilate adequately with a spontaneous regular rate and effort ?
    • if yes-continue monitoring, check pulse ox
    • if no-decide if they need intubated, give O2
  108. neuro assessment
    • head injury impairment
    • mild-13-15
    • moderate9-12
    • severe3-8
    • is the pt's GCS at 9 or above?
    • if yes-monitor, may need supplemental O2
    • if no-decide if you need to support airway
    • **a drop of 2 or more points in the total score is a dangerous sign of neurologic deterioration
  109. VS
    • is the pt's systolic BP above 90 and are there strong peripheral pulses??
    • if yes-keep monitoring may start IV
    • if no-monitor cardiovascular/fluid status, Foley esp with Dobutrex, Mannitol, lASIX-monitor UO
    • is the Cushing's Triad/reflex present??
  110. other assessments
    • assess ears and nose for CSF leaks
    • "Halo"-ring sign-test drainage for glucose:
    • dextrose sticks-it could be CSF or regular fluid so check, mucous has no dextrose

    • assess skull for signs of ecchymosis/hematomas
    • assess for nunchal rigidity-only after spinal injury is ruled out
  111. nursing diagnosis
    keep in mind the care of an unconscious pt and the pt with IICP

    • some questions to keep in mind with interventions:
    • how is an increase in ICP prevented?
    • how much fluid should the pt be given?
    • how is the pt protected from injury?
    • is CSF leakage is noted, what should you do?
    • how is adequate nutrition provided?
    • what is the pain med of choice?-codeine
  112. maintaining airway and preventing IICP
    • position to avoid extreme hip/neck flexion
    • elevate HOB 30 degrees, 30-45 degrees
    • log roll
    • O2 as needed
    • suction as needed
    • Mannitol
    • Lasix
    • IV fluids may be limited to help prevent overload
  113. maintaining fluid and electrolyte balance
    • monitor labs
    • I&O
    • Foley catheter
  114. preventing injury
    • observe for restlessness
    • possible causes:
    • seizure precautions-pad side rails
    • keep environmental stimuli to a minimum-low light, turn off tv, limit visitors, curtain/blinds closed
    • maintain sleep/rest cycle
    • orientation cues-make sure date/time is correct
    • skin care/eye care-can they close eyes, inc HOB (gravity for eyes)
    • watch out for sensory overload>>agitation
    • pain med-codeine, fentenyl
    • CSF drainage from nose>>2x2 dressing/tape
    • *don't blow nose, don't inhibit sneezes
    • CSF drainage from ear>>drsg over ear not inside ear, also protects from meningitis
  115. providing adequate nutrition
    • if an NG tube is needed-assess nose for CSF drainage first
    • use caution in inserting NG-an undiagnosed skull fracture could allow the NG tube to perforate into the brain
    • assess swallowing first before feeding-thickened liquids if trouble swallowing
  116. improving cognitive and sensory /perceptual functioning
    • *be aware there may be fluctuations in orientation and memory
    • *be aware that pt may experience a loss of sensation of pain, touch, temperature, proprioception (parietal lobe)
  117. post concussion syndrome
    • symptoms may last a few days>months>yrs
    • may affect employment

    • s/s:
    • headache, dizziness, easily fatigued, can affect work
    • impaired memory
    • problems with perception, reasoning
    • personality and behavior changes
  118. post-traumatic seizures r/t scarring of brain tissue
    may occur immediately or years later
  119. spinal cord injury
    • causes:
    • motor vehicle, falls, gunshot/stab wounds, sport injuries

    • incidence-12,000 new SCI every year
    • more common in 16-30 yr old males

    • mechanism of injury:
    • flexion-rotation: most unstable, severe neurologic deficits e.g. car accidents

    • **injuries usually occur in the cervical or lumbar area where there is the greatest mobility
    • ***any pt with a head injury, suspect a spinal cord injury
  120. damage to spinal cord rages from..
    • transient concussion
    • contusion
    • laceration
    • compression-lke a jump or fall
    • partial or complete transection
    • hyperextension-fall, whiplash
    • penetration-bullet
  121. most common sites of injury

    • C1-C4-respiratory paralysis
    • C1-C8-classified as a quadriplegic
    • T1-and below-classified as a paraplegic

    functional loss depends on site of injury and whether injury is partial or complete
  122. cords response to injury
    • *irreversible unless appropriate intervention
    • ischemia
    • edema
    • hemorrhage
  123. neurogenic shock
    • loss of vasomotor tone and impairment of autonomic function
    • (dec BP, bradycardia, warm/dry extremities), lasts 3 days-3 wks-peripheral vasodilation
    • tx-Dopamine/Dobutamine
  124. spinal shock
    • usually occurs with complete spinal cord lesions
    • immediate effect is confusion b/c of loss of spinal relflexes-type of neurogenic shock

    • the result is:
    • flaccid paralysis below the level of injury-absence of reflexes
    • areflexia-no reflexes>>spastic movements-e.g. toe twitches
    • loss of pain,sensation, and proprioception-e.g. sense of R and L, knowing what sides is moving
    • dec VS
    • loss of ability to perspire below the level of injury-skin may feel warm and dry
    • bowel and bladder dysfunction
    • phrenic nerve-if affected/interrupted>>dec respirations
    • *pt appears pink, warm and dry with vasodilation

    spinal shock develops w/i 2 hrs after injury and usually lasts 1-6 weeks
  125. how will you know when spinal sock is resolving?
    • spastic movement-twitching of lower extremities e.g. big toe twitches
    • once swelling is dec

    *better prognosis if movement occurs w/i first 48-72 hrs
  126. treatment of spinal shock
    • steriods to dec edema-methylpredisone (Solu-Medrol)
    • remember-use different steroids for different things

    supportive>>proper alignment to dec edema (Decadron) for head, Prednisone for rep, Solu-Medrol for resp, spinal edema, keep spinal cord straight, better if used w/i 8-24 hrs with steriods
  127. mgmt of pt with spinal shock
    • initial:
    • immobilization-cervical collar-if don't have, use hand or roll something up to stabilize neck, use jaw thrust for airway
    • assessment-ABC's (DON'T HYPEREXTEND NECK)
    • *modified jaw thrust
    • *focus on resp status of pt esp with C3-C5 injuries
    • look for neurologic deficits
    • extrication-move on back board-perdon at the head is the boss
    • stabilization and control of life threatening injuries
    • rapid and safe transport
    • suction if needed, intubation, meds-may need Atropine if bradycardic
  128. emergency room mgmt
    • assessment and monitoring VS and neuro checks
    • x-rays, CT, MRI
    • **Foley-atonic bladder? measure UO
    • NG-prevent aspiration pneumonia, ileus is common-may be difficult to insert b/c can't tilt neck
    • *steroids-Solu-Medrol to dec edema w/i 8-24 hrs
  129. surgical intervention for spinal shock
    • will try to do w/i the first 24 hrs
    • controversial-do benefits outweigh risks???
    • criteria for surgical intervention-
    • compound fractures, penetrating wounds
    • bone fragments in spinal cord
    • progressive neurologic deficits
  130. non-surgical mgmt
    • *immobilization by skeletal traction
    • Crutchfield or Gardner-Wells tongs-most common
    • traction typically 10-20#, maintained for 6 weeks
    • pain and muscle spasm decreases with vertebrae separated and aligned
    • special bed for turning-skin care
    • halo vest-for ppl who are mobile

    • *immobilization places pts at risk for-
    • hypoventilation-pt on back
    • pneumonia/atelectasis.dec ability to cough
    • pulmonary embolism b/c of immobility, SCDs, infection-pin care
  131. nursing interventions
    • potential complications to monitor for:
    • hypoxemia
    • urinary retention
    • DVT/PE
    • paralytic ileus
  132. nursing dx for spinal cord injury
    • ineffective airway clearance r/t high cervical injury
    • *prevent-atelectasis, infection, pneumonia

    impaired physical mobility
    r/t paralysis-watch for foot drop, wear high top shoes, don't leave on all the time, anti-spasmodics/anti-inflammtory

    anxiety r/t perceived effects of injury on life style and unknown future
  133. rehabilitation with spinal cord injury
    focus-coping with alterations in r/t ADLs, maintaining body function and preventing complications

    • impaired physical mobility r/t paralysis
    • prevent -contractures, joint alkalosis aka stiff joint, muscle shorteneing, skin breakdown

    • constipation-inc fluids, fiber, stool softener, bowel program, ROM
    • enemas are NOT used because they can retain edema and distend bowel

    • pain-from nerve root irritation @ level of injury from scar tissue (surgery, trauma)
    • -analgesics
    • -anti-spasmodics:
    • Baclofen-most common
    • Dantrium
    • Xanaflex
    • Botulism Toxin
    • *narcotics are contraindicated ig high cervical injury-resp depression
  134. SCI NSG DX cont
    impaired urinary elimination-encourage to drink 4000 ml/day to prevent calculi, cranberry juice, apple juice, vitamin C-acidifiers

    *UTI, renal calculi, pyelonephritis and hydronephritis were major causes of death-wth better urologic mgmt these have dec
  135. neurogenic bladder
    • full bladder 3300-500 ml triggers emptying
    • spastic reflex or automatic-upper motor neuron, spontaneous uncontrolled voidings
    • flaccid atonic, areflexic or autonomous-lower motor neuron, overflow incontinence

    *most common causes of death now appear to be pneumonia, PE and septicemia
  136. physiologic experiences common to SCI people
    **pt and families need to understand these
    • autonomic dysreflexia (hyperreflexia)
    • *occurs only with injuries abouve T6

    • s/s
    • pounding headache
    • blurred vision
    • nasal congestion
    • HTN (240-300/160
    • bradycardia>stroke>death
    • marked diaphoresis and flushing above the level of injury
  137. causes of autonomic dysreflexia (hyperreflexia)
    • *distended bladder or plugged Foley-most common
    • *constipation>>impaction-2nd most common
    • urinary calculi-UTI
    • uterine contractions with cramps or labor
    • pressure sores
    • hot/cold stimulus e.g. sitting in drafty hall

    • medical interventions-**this is a medical emergency
    • **elevate HOB check catheter, if don't have, check abd (intermittent foley cath-could straight cath, cath q4-6 hrs)
    • check for impaction
    • spray pressure sore-granulex
    • monitor BP
    • meds for elevated BP>>Apresolie, Hyperstat
    • if out and about, check to see if their clothes are too tight, like their belt, sit them up
  138. spasticity and muscle spasms
    • *as spinal shock clears, spasticity develops
    • spastic movements may be initiated by:
    • toush
    • bumping bed
    • cold weather
    • emotion-anxiaety, crying, anger, laughing
    • may last 1 1/2-2yrs but can disappear
    • spams may range from mild twitching to violent jerking

    • Interventions:
    • ROM 4 times a day-stiffness increases spasticity
    • limit tactile stimulation-be gentle, firm , and steady
    • avoid situations known to cause stimuli that increases spasticity-i.e. cold, prolonged sitting

    • meds:
    • Valium
    • Dantrium-skelestal muscle relaxant
    • Baclofen (Lioresal)-antispasmodic
    • surgery when muscle spasms are painful and can't be controlled i/e/ tendon release, chordotomy-for pain relief
  139. psychosocial aspects
    • grieving
    • risk for disturbed body image
    • interrupted family processes r/t adjustment requirements, role disturbances, and uncertain future

    • kids-long-term care will need to be planned for schooling?? vocational choices?? discipline and setting limits to help child become independent?? what will happen to child as parents age??
    • risk for altered sexuality pattern
Card Set